CASE STUDY On (hair-pulling disorder) TRICHOTILLOMANIA TTM (CLIENT-MASTER VIJAY)

CASE STUDY On (hair-pulling disorder) TRICHOTILLOMANIA TTM (CLIENT-MASTER VIJAY)
2
 Client’s Profile
I. Identification data
Client name : Master. Vijay
Age : 9 Years
Sex : Male
Father / Spouse name : Mr. Shridhar
Address : H: no 10/a govt lines
 Distt Hoshairpur.
Ward : Family Unit
Education : III standard
Occupation : Student
Income : -
Marital status : Unmarried
Religion : Hindu
Date of admission : 12/05/2012
Provisional diagnosis : Habit disorder
Final diagnosis : Trichotillomania
Informant : Father (Reliable)
 Mr. Shridhar Kumar (father) is staying with
 Master Vijay from 9 years. He is very
 much worried about client’s health and
 Showing concern about him. The
 Information is adequate and reliable.
II. Presenting Chief Complaints
o Pulling scalp hair
o Loss of hair from scalp in small areas 1 year
o Anxious mood
o Not interested in playing with peer group
III. History of Present Illness
Master Vijay is a 9 year old male child was apparently before one year. Since
last one year he is not performing well in school and not interested to play with
3
peer group. Usually he like to seat alone and anxious. He is continuous pulling
his scalp hair and having significant hair loss from scalp and eating the hair
also. He usually complains regarding stomach ache. He got admitted in
Dr.Vidya Sagar Institute Of Mental Health Amritsar on 12/05/2012 for further
investigation and treatment. He diagnosed as habit disorder. The final diagnosis
is trichotillomania.
IV. Family History
(a) Family Characteristics
S.
No.
Name of the
family members
Relationship
with the
Patient
Age
(yr.)/
Sex
Educational
Status Occupation Health
Status
Age &
mode of
death
1. Mr.Kailash kumar Grandfather - Illiterate
Shopkeeper
at grocery
shop
-
died at
the age
of 75
years
with
natural
death
2. Mrs.Krishna Grandmother - Illiterate Housewife -
Died at
the age
of 70
years wih
heart
attack
3. Mr. Shridhar Father 37/M MBA Manager Healthy -
4. Mrs. Kavery Mother 35/F B.A. House wife Healthy -
5 Mr. Kamal Brother 13/M 8
th Student Healthy -
6 Mr.Vijay Patient 9/M 3
Th Student
Trichotillo
mania
-
7 Ms.Gouri Sister 7/F 2
nd Student Healthy -
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(b) Genogram:
(Mr.kailash,died at (Mrs.Krishna, died at the
the age of 75 years) age of 70 years with heart attack)
(Mr.Shridhar ,37 yrs (Mrs.kavery, 35 yrs,B.A, Housewife)
MBA,Manager)

 13 yrs 9 yrs 7 yrs
 (mr.kamal,8th standard) (Mr,Vijay, 3rd std) (Ms.Gouri, 2
nd std)
There is no family history of psychiatric illness, alcoholism, suicide, epilepsy,
or endocrinological problems.
V. Socio-economic history
Master. Vijay is living in his own house. He is having nuclear family. His father
is earning member in his family working as a manager in private company.
Monthly income is 8000/- and belongs to middle income group. He is having
electricity and water facilities in his house. Ventilation is adequate. Drainage
facility is also hygienic. The living space is adequate.
VI. Treatment History
• Tab. Chlorpromazine – 25mg B.D.
• Tab. Diazepam – 1mg B.D.
• Tab.Imipramine – 25mg B.D.
VII. Past Psychiatric History
No significant past psychiatric history
Key:-
- Male
- Female
- Patient
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VIII. Past Medical History
No significant past medical history
IX. Past surgical History
There is no significant surgical history.
X. Personal History
(a) Perinatal history
Master Vijay delivered as full term normal vaginal delivery. He cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.
(b) Childhood history
Primary caregiver was mother. Weaning started at the age of 4-6 months
and all developmental milestones was achieved at appropriate age period.
There was no behavior and emotional problems like temper tantrums, head
banging, nail biting and enuresis except thumb sucking and that behavior
changed at the age of two year.
(c) Educational history
Education was started at the age of 5 years. He is average in academic
performance and had good relationships with teachers and peers. He never
dropout from school. No report of truancy.
(d) Play history
He used to play with both sex peer group and had good relationship with
peers.
(e) Emotional problems during adolescence
There is no significant history of emotional problems like aggressiveness
and assault.
(f) Premorbid personality
i. Interpersonal relationships : Introvert
ii. Use of leisure time : Watching T.V.
iii. Predominant mood : Mood alteration
iv.Attitude to self and others : Behaving normally with others.
XI. Physical Examination:
During physical examination all the finding found normal expect
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(a)Scalp – Loss of hairs caused small areas of baldness

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